HIV/STI monitoring and evaluation among hidden populations

1. HIV/STI monitoring and evaluation among hidden populations Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT)

2. Outline • Epidemiological surveillance in hidden populations. • HIV-COBATEST project.

3. Who are the hidden groups? • “Groups who reside outside the institutional and clinical space and whose activities are “clandestine” and therefore distant from the majority viewpoint” (Singer, 1999). • Populations that are hard to find, hard to retain in interventions, and hard to track in assessment studies. • Public health problem: risk of infection (perceived or real) and fear that infections could be transmitted to the rest of the population. • Some populations are more hidden than others (e.g. men who practice bareback sex among MSM, inmigrants who are sex workers).

4. Bio-Behavioural Surveillance in Catalonia behaviour morbidity mortality testing As part of integrated HIV/STI surveillance in Catalonia, Bio-Behavioural Surveillance was introduced in 1993.

5. Intravenous drug users Men who have sex with men Female commercial sex workers Populations 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

6. To describe changing patterns in risk behaviours and HIV-testing behaviours. To describe changing patterns in the prevalence of HIV and other Sexually transmitted Infections (STI). To identify predictive variables of HIV/STI risk behaviours Objectives of our surveillance system

7. Cross-sectional surveys Collaboration with NGOs that carried out the survey fieldwork Non-probability sampling methods in key groups: Methods: Where recruit hidden groups? • MSM:Conveniencesample of men recruited in gay venues (saunas, sex-shops, bars and a cruising site in a public park) and through the mailing list of a gay community based association. • IDU: Convenience sample of IDUs recruited in Harm Reduction Centers (since 2008), stratified by country of origin. • FSW: Convenience sample in commercial sex establishments (brothels, bars…), private apartments and in the street, stratified by Catalan region of recruitment and by country of origin.

8. Anonymous questionnaires to explore risk behaviours: MSM: Self-administered questionnaires were either conducted face to face by gay-association health educators in gay venues or mailed to the mailing list of a gay-community association, and returned by mail. IDU: Face-to-face interviews were conducted by trained interviewers. FSW: Face-to-face interviews were conducted by trained interviewers. Methods: What instrument?

9. Biological samples (anonymous) Methods HIV IDU, MSM, FSW HCV IDU C. Trachomatis FSW, IDU (2008) N. Gonorrhoeae FSW, IDU (2008)

10. Direct sharing (last 6 months). IDU 1993-2006 * p<0.005

11. Unprotected anal intercourse among MSM (1995-2008)

12. Samples are not probabilistic. Caution should be used in generalizing the findings. Possible biases concerning memory and under-reporting of risk behaviours. Cross-sectional study: cause-and-effect could not be established. Limitations

13. Applicability of the Bio-Behavioral Surveillance • Early alert system indicating which populations may be more vulnerable to HIV/STI. • Information about behaviors associated with HIV/STI transmission to be incorporated to prevention programmes.

14. Participation in European projects 2008-2010. SIALON: “Capacity building in HIV/syphilis prevalence estimation using non-invasive methods among MSM in Southern and Eastern Europe” (SIALON) 2009-2011. EMIS: “European MSM Internet survey on knowledge, attitudes and behavior as to HIV and STI” (EMIS)

15. HIV-COBATEST:HIV community-based testing practices in Europe 2010-2013 www.cobatest.org

16. Purpose and objectives The purpose of the project is to promote early HIV diagnosis in Europe by means of improving the implementation, monitoring and evaluation of community-based counseling and testing practices (CBVCT)

17. The specific objectives are: • To gain a thorough understanding of CBVCT programmes and services in different countries. • To identify and describe good practices in the implementation of CBVCT. • To identify a core group of indicators that can be used to monitor and evaluate CBVCT. • To establish a network of community-based VCT in which to perform operational research. • To assess the acceptability, feasibility and impact of introducing oral rapid test technologies at community-based VCT.

18. Participants Associated Partner (10) Collaborating Partner (14)

19. Associated partners: • Projecte dels Noms (Spain) - Ferran Pujol • Regional Centre for Health Promotion (Italy) - Massimo Mirandola • AIDES (France) - Jean MariLe Gall • STOP AIDS (Denmark) - Klaus Legau • Institute of Sexology, Medical Faculty, Charles University (Czech Republic) - Ivo Prochazca • National Institute of Public Health (Slovenia) - Irena Klavs • National AIDS Centre (Poland) - Ivona Wawer • AIDS-Hilfe NRW e.V. (Germany) - Michael Wurm

20. Collaborating Partners: • Arcigay, Italy. Michele Breveglieri • SKUC, Slovenia. Miran Solinc. • Ceska spolecnost AIDS pomoc. Czech Republic. Petr Hájek. • Romanian National Antidrug Agency, National, Romania. Andrei Botescu. • Karolinska University Hospital, Sweden. Veronica Svedhem. • Laboratory for Molecular Microbiology and Slovenian HIV/AIDS Reference Centre, Slovenia. Mario Poljak. • Institute of Public Health of Montenegro. Boban Mugosa. • Prolepsis, Greece. Eleni Patrozou. • Sexual Health Promotion & Evaluation Department HIV/STI Centre for Infections Health Protection Agency, United Kingdom. Anthony Nardone. • Program for AIDS Prevention, Health Departament, Generalitat de Catalunya, Spain. Albert Giménez. • State Agency Infectology of Latvia. Inga Upmace. • GAT Portugal. Luis Mendau • Legebitra, Slovenia. Miha Lobnik • Red Cross Luxemburg

21. An ongoing project… • Work in progress… • Visit our website: www.cobatest.org • For further information, please mail to: cab.ceescat.germanstrias@gencat.cat

22. Lessons learned • Workings with hidden populations presents significant challenges to conduct useful research, challenges that will have to deal with the development of special sampling strategies as well as recruitment and retention strategies. • Maintaining a positive relationship with community organizations (NGOs) can help reach certain hidden populations as well as to facilitate cooperation between research and community services.

23. Thank you!!